Basic Information
| Provider Information | |||||||||
| NPI: | 1932185576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLTJEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CNM CRNP RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GERNER | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 623 UNRUH AVE | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191114709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152141094 | ||||||||
| FaxNumber: | 2152141098 | ||||||||
| Practice Location | |||||||||
| Address1: | 7604 CENTRAL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157458989 | ||||||||
| FaxNumber: | 2157459072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN279256L | PA | X | Nursing Service Providers | Registered Nurse | 363L00000X | TP004106G | PA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SW0102X | MW008564L | PA | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Women's Health |
No ID Information.